STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.
First Appeal No.177 of 2019
Date of institution : 01.04.2019
Date of decision : 11.04.2019
Charanjit Singh aged about 68 years s/o Sohan Singh, retired Assistant Engineer, Water Supply & Sanitation, Mansa now resident of H.No.1, Ward No.5, Railway Road, Budhlada, Tehsil Budhlada, District Mansa.
…….Appellant/Complainant.
Versus
- M.D.India Health Insurance TPA Pvt. Ltd., Shop No.46/1, E-Space, A-2 Building, 4th Floor, Pune Nagar Road, Vedgaonsher, Pune 411 014 through its competent authority/Managing Director.
- M.D.India Health Insurance TPA Pvt. Ltd., Maxpro Info Park, D-38, 1st Floor, Industrial Area, Phase-I, Mohali, through its Project Officer.
- The Oriental Insurance Company Limited, Mansa through Divisional Office, Bank Branch, Bathinda.
. ……..Respondents/Opposite Parties
First Appeal against the order dated 11.02.2019 of the District Consumer Disputes Redressal Forum, Mansa.
Quorum:-
Hon’ble Mr. Justice Paramjeet Singh Dhaliwal, President
Ms. Kiran Sibal, Member
Present:-
For the appellant : Sh.Aervinder Singh, Advocate
JUSTICE PARAMJEET SINGH DHALIWAL, PRESIDENT:
The instant appeal has been preferred against the order dated 11.02.2019 passed by District Consumer Disputes Redressal Forum, Mansa (in short, “District Forum”), whereby the complaint filed by the complainant against the opposite parties (in short ‘OPs’) under Section 12 of the Consumer Protection Act, 1986 (in short ‘C.P.Act’) was dismissed.
2. It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Forum.
3. Brief facts of the case are that complainant, being pensioner of Punjab Government employee along with his wife is covered under the 'Punjab Government Employees & Pensioners Health Insurance Scheme' ('PGEPHIS'), undertaken/sponsored by the Oriental Insurance Company. Complainant has been issued ID Card No.MDIS-09872232585 for general and cashless medical treatment by OP No.1. He alleged that, he remained admitted for medical treatment as indoor patient with DMC & Hospital, Ludhiana from 2.9.2016 to 7.9.2016 and spent Rs.61,442/- for Prostrate operation. The payment was deposited by the OPs in the bank account of the complainant. Thereafter, he remained admitted in the same hospital from 26.9.2016 to 1.10.2016 for recurrence of Inquival Hernia and paid Rs.50,149/- on the treatment. Both the reimbursement bills of Rs.61,442/- and Rs.50,149/- were submitted, complete in all respect, jointly to the OPs on 11.11.2016. Payment of bill of Rs.61,442/- had already been deposited in the account of the complainant, but reimbursement of Rs.50,149/- has not been made despite contacting OPs time and again. The OPs telephonically replied that claim has been repudiated on the ground that DMC & Hospital, Ludhiana is not on the panel of the OPs. He served legal notice dated 06.03.2017 on the OPs but no response was received. It was alleged that the repudiation of the claim is illegal, which amounts to 'deficiency in service' and 'unfair trade practice' on the part of OPs. OPs have violated the terms and conditions of the scheme. He suffered mental and physical agony and harassment. He filed consumer complaint before the District Forum with a prayer for directing to OPs to reimburse the amount of Rs.50,149/- and to pay interest @ 18% per annum on the amount, besides compensation of Rs.20,000/- and Rs.15,000/- as ligation expenses.
4. Upon notice OP No.3 filed its written statement raising legal objections that complainant is not a consumer of OPs as per the definition of Consumer under the C.P.Act. There was no insurance contract between the beneficiary and Insurance Company. There is no point of contractual liability. There is no consideration taken from the complainant by the Company. Punjab Government has sponsored the scheme to its employees and pensioners and no insurance consideration is deducted from their salaries. It is provided free of costs. In principle, the Insurance Company has contractual liability towards Punjab Government only. Now in Punjab and Chandigarh no reimbursement will be available for the treatment where cashless treatments if available. Moreover, DMC&H, Ludhiana is not on approved list of panel of hospitals. Cashless claim is payable in case of emergency admission for the treatment obtained from un-empaneled hospital. First amount was paid for emergency admission and second amount was for planned admission which is not payable. As per Para No.4 of the notification dated 20.10.2015, claim was correctly repudiated. The complainant has no cause of action and locus standi to file the complaint and it was bad for misjoinder and non-joinder of necessary parties. The complaint is vexatious to the knowledge of the complainant. Complainant suppressed the material facts from the Forum and has not come to the Forum with clean hands; OP No.3 had been impleaded without any cause of action and he should have lodged the claim within 30 days from the date of availing the benefit. He failed to submit the claim form. His claim was rejected on the reasons of delayed submission. As per the rules and regulations, the empaneled hospitals shall reimburse the cost of treatments as per the 'PGEPHIS' package rates with the hospital. Insurance Company shall settle the claim of the hospital within 15 days of the receipt of the complete bills alongwith discharge summary. In this case, the claim was not payable and it was correctly repudiated; District Forum has no jurisdiction to adjudicate upon the matter; That in all, payment of Rs.1,11,591/- was demanded, but competent authority recommended for reimbursement of Rs.61,442/-, which has already been paid as per 'PGEPHIS' rates. Items which were not payable were not paid. On merits also, the OP No.3 had reiterated its stand as taken in the legal objections and denied all the other averments of the complainant and prayed for dismissal of the complaint.
5. OPs No.1&2 did not file separate written reply, but they have adopted the written reply filed by OP No.3.
6. Both the sides produced evidence in support of their respective averments before the District Forum, which after going through the same and hearing learned counsel on their behalf, dismissed the complaint, vide impugned order. Hence, this appeal.
7. We have heard learned counsel for the appellant/complainant at the admission stage of the appeal and have carefully gone through the records of the case.
8. Learned counsel for the appellant/complainant has vehemently contended that appellant took the treatment from DMC&H, Ludhiana on two different times i.e. from 02.09.2016 to 07.09.2016 and then from 26.09.2016 to 01.10.2016. He submitted bills of Rs.61,442/- and Rs.50,149/- respectively of both the treatments. OPs had reimbursed Rs.61,442/- but they repudiated the claim of Rs.50,149/-, vide letter dated 21.03.2017. The reason for repudiation is that admission was in non-empanelled hospital in non-emergency case, despite the fact that OPs have reimbursed the claim of Rs.61,442/- for the treatment taken from the same hospital i.e. DMC & H, Ludhiana and repudiated the claim for subsequent period. The District Forum has wrongly and illegally dismissed the complaint of the appellant as such the impugned order is liable to be set-aside and the complaint deserves to be allowed, and the reliefs claimed in the complaint may be granted.
9. We have given our thoughtful consideration to the contentions raised by the counsel for the appellant.
10. Admittedly, the complainant has taken treatment from DMC&H, Ludhiana twice, firstly from 02.09.2016 to 07.09.2016 spending Rs.61,442/- and then from 26.09.2016 to 01.10.2016 and spent Rs.50,149/-. He submitted the bills for reimbursement. The OPs reimbursed the amount of Rs.61,442/- of the first treatment but repudiated the second claim of Rs.50,149/-. Para 4 of the Notification No.21/28/12-5HB5/268 dated 20.10.2015 issued by the Govt. of Punjab, Department of Health and Family Welfare ( Health- V Branch) reads as under:-
“The treatment can be taken by any enrolled beneficiaries in Government or in empanelled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). Further details of the scheme can be seen on website www.pbhealth.gov.in. No reimbursement will be available to employee/pensioner in the Punjab, Chandigarh and Panchkula, where cashless treatment is available. However, reimbursement can be taken by employee/pensioner for medical treatment taken in any other State in India in exceptional circumstances, in such circumstances, the insurance company will reimburse the bill of the employee up to Rs.3.00 lacs as per the package rates defined under the scheme.”
11. As per the notification and rules, we are of the view it was not a case that emergency treatment was required which is not in exceptional circumstances. This is an ordinary surgery and if the treatment was taken from the empanelled hospital, the complainant would have been entitled to reimbursement. Otherwise also he can avail medical reimbursement facility, which are available to the employees by the State Government according to the Rules. It needs to be emphasized that DMCH is not empanelled hospital as per the notification. Merely on the ground that one payment has been made by the Insurance Company, does not mean that they are required to reimburse the subsequent bill also. It is always within the jurisdiction of the Insurance Company to refuse if the same is not according to the contract between the State Government and the Insurance Company. If the payment is made for one of the bills by mistake, the same cannot be taken as ground for making the payment of subsequent bills. The authorities are always at liberty to rectify their mistake in subsequent matters. Learned counsel has failed to point out the exceptional circumstances under which he was required to go for surgery in that hospital and this was an emergency case.
In view of above, we do not find any merit in the appeal and the same is dismissed in limine.
(JUSTICE PARAMJEET SINGH DHALIWAL)
PRESIDENT
(KIRAN SIBAL)
MEMBER
April 11, 2019.
Rupinder 2
